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Wednesday
Dec222010

Pre-Holiday Induction of Labor without Medical Indication

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By Jill

For the last few years, people have asked me for links about pre-holiday inductions. Here are the posts that everyone ends up passing around on Facebook, plus a few more.


Childbirth educator and About.com blogger, Robin Elise Weiss, has observed an uptick in pre-holiday inductions.

One of the things I’ve noticed year after year is that there is an increase in the induction rates just before holidays, but truly a lot of them occur before the winter holidays, oh and the end of the tax year. I remember one year I had three women due around Thanksgiving. One went into spontaneous labor the Sunday before Thanksgiving. One choose to be induced Monday morning so that she could be home in time for Thanksgiving (She was 38 weeks.) and the third choose to be induced that Tuesday for the same reason. I was crazy busy - but so were the hospitals. My clients who were scheduling induction kept getting bumped by others in the same situation. The real kicker here is that none of these women had medical reasons to be induced.

 

Lamaze’s Giving Birth with Confidence blog featured a post in November about the trend.

“Few doctors want to be pacing the halls on Thanksgiving or Christmas, waiting for a mother to deliver,” said Marilyn Curl, CNM, MSN, LCCE, FACCE and president of Lamaze International.  “So it’s not uncommon to see a surge of women with normal pregnancies being told that there might be an issue and that they should consider scheduling the delivery, coincidentally, right before a holiday.” 

It’s not just your healthcare professional who may try to rush your baby’s arrival.  Families often can feel stressed about the uncertainty of the baby’s arrival and feel it may compromise the celebration of holidays.  Some women also fear that their preferred healthcare provider won’t be available and will agree to a scheduled early delivery to guarantee that their provider will be available for the birth.

“I really understand that pressure.  You build a relationship with your care provider over the course of a pregnancy.  Plus, you build up expectations about your holiday celebration.  So it seems like ‘no big deal’ just to get the birth over with,” said Sue Galyen, RN, MSN, HCHI, LCCE, FACCE, a Lamaze childbirth educator from Brownsburg, IN.  “But it’s so hard to think that a scheduled delivery, whether through induction or cesarean, was worth it when either the mother or baby experiences a complication as a result.”

 

Lamaze lists red flags that may signal to a pregnant woman that she is being pressured into or feeling like scheduling an unnecessary induction and risking avoidable prematurity of her baby:

• The care provider suggests that the baby is too big and will be easier to deliver “a little early” 
• The suggestion is made that the care provider won’t be available for a holiday delivery or will be “booked up”
• The timing of the delivery is centered on travel and celebration schedules
• Holiday stress is driving feelings of wanting to get the pregnancy “over with”

 

Blogger Leah describes her experience of being offered a medically unnecessary induction.

Of course, this isn’t just a normal, uncomplicated time of year to be dealing with everything labor- and birth-related, what with so many planned events depend on this one UNplanned event: we have family coming in from out of town, out of state, and out of the country this month, and then there’s the whole stress of not just giving birth in the days before Christmas 2008 year but having a child whose birthday forever rubs up against the busiest time of the year every year. Everyone keeps telling me that I should take advantage of this excuse for not going all out with decorations and shopping and homemade gifts and baking (baking for others, at least) this Christmas, but I still can’t help thinking about what it will be like NEXT year, and the year after that and the year after that, when I have to throw in a birthday party on top of everything else. It would be so much easier if the baby were coming in early December rather than mid- or late December. Or, you know, July. (We’ve actually discussed the possibility of half-birthday celebrations to avoid this conflict.)

Which brings me to my point. At a prenatal appointment a few weeks ago, I was mentioning how very much I hope the baby comes early so as to make the whole holiday/family situation easier on everyone, and my doctor’s response was, “Well, when would you like to schedule an induction? Does December 7 work for you?” Although I was taken aback that she seemed not only willing but eager to accommodate me in this way, I was mostly surprised at my reaction to the idea of induction in general. I hadn’t ever seriously considered it before then, so I wasn’t quite prepared to have reacted the way I did, which was negatively.

 

Only slightly related is the CDC’s 2009 post, What’s your chance of having a Christmas baby?

The short answer is, not as high as in other months. Still, the possibility is there. In fact, if you look at the seasonally adjusted birth rates by month, your chances in December are just as good as having a baby in March or May. The lowest rate is April (13.7 live births per 1,000 population), compared with the highest rate in August (14.6). December comes in at 14.2 births per 1,000 population.

But this year, Christmas is on a Friday. How does that figure in? Well, the average number of births in 2006 (most recent data available) ranges from 7,587 live births on Sundays compared with 13,482 on Wednesdays. Fridays come in at a respectable 13,151, although Tuesdays and Thursdays, along with Wednesdays, have a higher average.

But then, that baby will come when it comes, right?

 

In the oft shared 2006 New York Times article, To-Do List: Wrap Gifts. Have Baby, David Leonhardt discussed tax breaks and the rise in December births.

 “[S]ince the early 1990s — the federal government has been steadily increasing the tax breaks for having a child. For parents to claim the full amount of any of these breaks in a given year, a child must simply be born by 11:59 p.m. on Dec. 31. If the baby arrives a few minutes later, the parents are often more than a thousand dollars poorer.

Unless you’re a cynic, or an economist, I realize you might have trouble believing that the intricacies of the nation’s tax code would impinge on something as sacred as the birth of a child. But it appears that you would be wrong.

[…]

“It’s phenomenal what’s happening in late December,” said Amitabh Chandra, a Harvard economist who provided many of the numbers here. “December is not really a particularly busy time for babies to be born. So to see a spike that’s equal to September is astounding.”

 

Jon Peltier of Peltier Technical Services, Inc., plotted data in response to the Leonhardt commentary in the New York Times and arrived at the conclusion that there is a “holiday effect” separate from the so-called “tax break babies” phenomenon because the New Year’s dip in numbers is not as pronounced as those at Thanksgiving and Christmas.

When a more complete record of the data is viewed, the assertion of the New York Times article can be examined more closely. It is obvious that births on 1 January are markedly lower than would be expected for the day of the week. Births on 25 December (Christmas Day) are also lower than expected for the day of the week, by an even greater amount than the New Year’s Day variation. In fact, the day of the year with lowest number of births is Christmas Day. Thanksgiving also shows a pronounced decrease in births compared to typical Thursdays, and perhaps more of an effect than New Year’s. The day of the year with the greatest number of births is either the Tuesday before Thanksgiving (as in 2000), the Tuesday before Christmas (1999), or the Tuesday before New Year’s (1998).

It is evident that more births are induced just before these three holidays, so the patients and doctors are not tied up during the holidays. I plotted data for the entire year 2000 to see whether this was true for other holidays during the year. The blue line shows the actual data, while the red line shows the value for each day of the week averaged over the whole year. Sure enough, while the general weekend-weekday pattern held for most weeks of the year, the chart below shows that Memorial Day, Independence Day, and Labor Day also had declines in number of births compared to the expected number for the day of the week. These declines were significant but not as pronounced as those on Thanksgiving, Christmas, and New Year’s Day.

Click over and scroll down to view this graph 

“Ask Kitty” columnist, Kitty Schindler, wrote the following a post titled Don’t short-change your baby by inducing labor on the TODAYMoms blog.

And that’s what disturbs me most about this trend: There are many valid reasons for inducing labor which mother and doctor can decide together, but CONVENIENCE is not one of them.

To bring a healthy baby into the world is such a joy; why take chances? Those last weeks, uncomfortable though they may be, allow further time for development of vital organs. What could possibly take priority over time to allow baby’s heart, lungs and brain to fully mature?

I say: Give your baby the best chance for a great start in life. Don’t short-change him or her in the final weeks of pregnancy after putting in so much time already.

 

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Reader Comments (19)

This is a GREAT piece pulling all this together, Jill, thank you! Bet it will get bookmarked like crazy.

December 23, 2010 | Unregistered Commenteremjaybee

My second son was breech and due on 12/23/06. I got a lot of pressure to schedule a c-section well before Christmas, like in the 38-week range, as soon as external cephalic version failed. I really wanted to wait for labor to begin before making a decision about having a c-section or not (was having no luck finding someone to do a vaginal breech delivery but still had some hope). I declined an early c-section but reluctantly scheduled a c-section for 12/27, four days after my due date, and was directly told by the OB that "no one is going to be happy if you show up in labor on Christmas with a breech baby." You would think that people who work in obstetrics and in hospitals would accept the lifestyle that goes along with it, meaning that some babies are going to be born at inconvenient times, like on holidays. I still wish I had waited for labor, even if it had still ended up with a c/s. My next son was a VBAC.

December 23, 2010 | Unregistered CommenterKK

My mom was scheduled to be induced with me 30 years ago on 12/22 because I was due on Christmas (she went in to labor spontaneously on the morning of her induction).

December 23, 2010 | Unregistered CommenterLisa

I love the quote, "What could possibly take priority over time to allow baby's heart, lungs and brain to fully mature?" from the Don't short-change your baby by inducing labor article. Thanks for sharing.

December 23, 2010 | Unregistered CommenterMama&Ellie

Interesting article due to the fact that I was just alerted this morning to a mom who was induced yesterday (unsure of the actual reasons) and she passed away this morning of an amniotic embolism. Sigh. It's just so sad. And in most cases--unneccessary.

December 23, 2010 | Unregistered CommenterBrittany

I have two comments about this...

1) I am not surprised that the holidays have a bigger impact than taxes, which as far as I'm concerned points to provider convenience being a bigger factor than patient convenience. That may be a big "duh," but just saying. While both patients and providers could be influencing inductions prior to Christmas and Thanksgiving, providers don't get an earlier tax deduction for a baby born December 31, so they likely have less influence over that. This all just goes to show that women aren't demanding elective C/S, inductions, etc., nearly as much as doctors/midwives/et al. are pushing them (subtly or directly) and is yet one more data point in the argument to stop blaming women.

2) Someone I know of on an online community recently (within the last week) posted a question to two boards about her doctor recommending induction because her baby is "already 8 lbs" according to U/S at 38 weeks. Both boards (one dedicated to natural birth, one a general pregnancy board) called the reasoning bogus, and both boards brought up the possibility that the doctor was getting antsy because of Christmas. But on the general board, there were also a few rushing in to defend the doctor with the underlying assumption that doctors rarely schedule convenience inductions, they almost never recommend anything unsafe, etc. To that, I must say again-- when you're a hammer, everything looks like a nail. While there are no doubt docs and other HCPs that schedule C/S around their golf games, I believe they make up a relatively small percentage of the whole. I think the bigger problem is much subtler and far more injurious. And that is that so few OBs (in particular) witness normal, low-intervention births, that they do not see inductions, C/S, etc. as a "big deal," particularly preventable nor worth preventing. If you believed all were equal, why not schedule inductions before the holidays? It doesn't even have to be all that conscious a push or an inclination. You may also think, well, it'll be better for the mom-- less stressful-- and she'd have less "assistance" in a relatively understaffed hospital if she went into labor on December 24 or 25 (which would be a bad thing).

Honestly, if most of what you witness (and do not believe you cause) are inductions leading to C/S a good percentage of the time... Well, you'd rather "be there" for your patient than have her subject to whoever's on call, right?

I firmly believe that current OB practice in the US leads to poorer outcomes for mothers and babies overall AND that most OBs believe they are working in the best interests of mothers and babies, and are not disproportionately income-driven in their motivations (as compared to most other MDs or even most other people). I feel as though those defending doctors with the reasoning that they would never recommend something injurious are missing the point. You can defend a doctor's motivations (they're not necessarily all about money, nor is the doc necessarily-- or even likely-- acting callously) without believing they would only recommend a course of action if it were the best, evidence-based one.

Honestly... And feel free to skip this next part, but it's something I've been thinking about... This is a really common disconnect I've seen in all sorts of arguments about making "the right choice." It could be about birth, it could be about anything. One group insists that X is the way to go, it has certain benefits, and that it doesn't cost much to do X, therefore it should be done. The second group says, well, X may not cost much, but it costs something and it doesn't provide any benefit either, so why do it? The first group tries to debunk what the second group says is the cost of X, but they're missing the point. The second group sees NO or VERY LITTLE benefit to X, so it doesn't matter if X costs a little or almost nothing.

For example-- I say to you as a fellow printer that you should include a piece of tissue paper in every wedding invitation. We no longer use the engraving process that would make this essential to prevent ink transfer, but people are used to it, and enough old-fashioned people who care would be annoyed if they didn't see it... so it's worth the extra piddling expense. And you say to me, no, it really doesn't matter, so few care as to be a non-issue (and those who do care are barely annoyed) and I'd rather save the $2 per 250 invitations and the extra 20 minutes of labor to insert the tissue. So I come back and say, well, it only takes $1 and 10 minutes for me. And you say, well, that's still $10 and 1-2 hours/week. And I say, well, you could do it while you're watching TV, and what's $10? And we go on and on in a pointless dance because the bottom line is YOU DON'T SEE THE BENEFIT.

themidwifenextdoor.com just had a great post that illustrated this when it comes to the mindset of many OBs.

http://www.themidwifenextdoor.com/?p=1331

"He goes on to argue that in a day when use of forceps is a lost art, and every woman has an epidural, and doctors are surgically trained, we must accept a higher C-section rate. “I don’t think this is bad,” Dr. Frischer argues. “Why would w want to risk a lifetimes’ financial achievement in a lawsuit, just to say we lowered the c-section rate?""

Because he DOESN'T SEE THE BENEFIT in lowering the C/S rate. Not necessarily because he (or OBs like him, at least) are money-hungry or callous. But because they have accepted the current state of affairs as "natural" or pre-determined and the alternatives (imagined rampant cases of shoulder dystocia*, etc.) are too scary because they're "unknown" (at least to the OBs). Docs like Dr. Frischer, for the most part, would not schedule 39-week inductions on December 22 because they don't care about their patients. Suggesting that they are doing it for some form of convenience is only an attack on OMGEVILDOCTORS if we assume they know what they're doing, in a sense. If we assume that they understand and believe that such inductions are somewhat likely to end in C/S or other unnecessary interventions and higher morbidity. But the problem is, most of them don't. THAT is the problem. The ignorance of normal birth, the lack of evidence-based practice and the acceptance of that. Not callousness and greed-- or at least not exclusively or even largely callousness and greed.

People defending doctors when we point out these things are betraying the fact that they assume OBs largely practice evidence-based medicine. Because in their minds, if it were not evidence-based, the doc wouldn't do it. And if the doc wants to do it, it must be evidence-based. Which means that anyone who disagrees with the doc's recommendations MUST be assuming that the doc is consciously doing something NOT evidence-based out of malice or callousness.

But this is not necessarily so. The disconnect is that we are aware how little evidence-based practice exists in OBs dealing with normal birth.


*When the vast majority of unnecessary/iatrogenic C/S are done on women whose babies are unlikely to have SD.

December 23, 2010 | Unregistered CommenterDreamy

In my experience, inductions are done not for NO reason, but for a lot of little reasons that don't add up to a sum total of true risk to mom or baby. It happened to me--BP, oligohydramnios, etc, until the doc just sent me on my way to L&D after my 40 week appointment. Thank God it turned out fine and I delievered a healthy baby girl without medication (including Pitocin).
My cousin was induced this week just shy of 39 weeks. Doc was telling her the baby was big, her BP was "creeping up," baby wasn't "practice breathing" so no reason to keep her in there, etc. She delivered a 6 lb. 10 oz. er three days before Christmas. Seems like that baby could have cooked until the 29th, you know?

December 23, 2010 | Unregistered CommenterKylie

I vote for Dreamy's post as "comment of the week!" :-D

December 23, 2010 | Unregistered CommenterKathy

"To bring a healthy baby into the world is such a joy; why take chances? Those last weeks, uncomfortable though they may be, allow further time for development of vital organs. What could possibly take priority over time to allow baby’s heart, lungs and brain to fully mature? I say: Give your baby the best chance for a great start in life. Don’t short-change him or her in the final weeks of pregnancy after putting in so much time already."

I quoted this, almost verbatim, to my SIL on the 12/6. Her baby was born a few days later because she "didn't care how s/he was born, I am done." Well, the baby is now 2 weeks old and still in the hospital. Nobody will tell me why and I found out by accident. My mind is reeling---my mom said something about jaundice, but come on, 2 weeks for jaundice? Not likely. RDS? CLD? Botched circ?

WTF is wrong with our society!? Why can't we just let babies do their thing in their own time? It sickens me to no end that our society puts tax returns, discomfort, and schedules above the health of a newborn.

****head meets keyboard*****

December 23, 2010 | Unregistered CommenterMM

Awesome post. And o holy shite, I had not seen that graph of birth by day. I just cannot even.

December 23, 2010 | Unregistered CommenterAnother Rachel
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